Total Duration Of Antibiotic Treatment Research Articles

Transition to Oral Antibiotic Therapy for Hospitalized Adults With Gram-Negative Bloodstream Infections

Management of gram-negative bloodstream infections (GN-BSIs) with oral antibiotics is highly variable. To examine the transition from intravenous (IV) to oral antibiotics, including selection, timing, and associated clinical and microbial characteristics, among hospitalized patients with GN-BSIs. A retrospective cohort study was conducted of 4581 hospitalized adults with GN-BSIs at 24 US hospitals between January 1 and December 31, 2019. Patients were excluded if they died within 72 hours. Patients were excluded from the oral therapy group if transition occurred after day 7. Statistical analysis was conducted from July 2022 to October 2023. Administration of antibiotics for GN-BSIs. Baseline characteristics and clinical parameters reflecting severity of illness were evaluated in groups receiving oral and IV therapy. The prevalence of transition from IV to oral antibiotics by day 7, median day of transition, sources of infection, and oral antibiotic selection were assessed. Of a total of 4581 episodes with GN-BSIs (median age, 67 years [IQR, 55-77 years]; 2389 men [52.2%]), 1969 patients (43.0%) receiving IV antibiotics were transitioned to oral antibiotics by day 7. Patients maintained on IV therapy were more likely than those transitioned to oral therapy to be immunosuppressed (833 of 2612 [31.9%] vs 485 of 1969 [24.6%]; P < .001), require intensive care unit admission (1033 of 2612 [39.5%] vs 334 of 1969 [17.0%]; P < .001), have fever or hypotension as of day 5 (423 of 2612 [16.2%] vs 49 of 1969 [2.5%]; P < .001), require kidney replacement therapy (280 of 2612 [10.7%] vs 63 of 1969 [3.2%]; P < .001), and less likely to have source control within 7 days (1852 of 2612 [70.9%] vs 1577 of 1969 [80.1%]; P < .001). Transitioning patients from IV to oral therapy by day 7 was highly variable across hospitals, ranging from 25.8% (66 of 256) to 65.9% (27 of 41). A total of 4109 patients (89.7%) achieved clinical stability within 5 days. For the 3429 episodes (74.9%) with successful source control by day 7, the median day of source control was day 2 (IQR, 1-3 days) for the oral group and day 2 (IQR, 1-4 days) for the IV group (P < .001). Common infection sources among patients administered oral therapy were the urinary tract (1277 of 1969 [64.9%]), hepatobiliary (239 of 1969 [12.1%]), and intra-abdominal (194 of 1969 [9.9%]). The median day of oral transition was 5 (IQR, 4-6 days). Total duration of antibiotic treatment was significantly shorter among the oral group than the IV group (median, 11 days [IQR, 9-14 days] vs median, 13 days [IQR, 8-16 days]; P < .001]. Fluoroquinolones (62.2% [1224 of 1969]), followed by β-lactams (28.3% [558 of 1969]) and trimethoprim-sulfamethoxazole (11.5% [227 of 1969]), were the most commonly prescribed oral antibiotics. In this cohort study of 4581 episodes of GN-BSIs, transition to oral antibiotic therapy by day 7 occurred in fewer than half of episodes, principally with fluoroquinolones, although this practice varied significantly between hospitals. There may have been additional opportunities for earlier and more frequent oral antibiotic transitions because most patients demonstrated clinical stability by day 5.

Trueperella pyogenes endocarditis in a Swiss farmer: a case report and review of the literature

BackgroundTrueperella pyogenes (T. pyogenes) is a bacterium that colonizes the skin and mucosal surfaces of various domestic and wild animals. It rarely leads to infections in humans, with only a few descriptions available in the literature.Case presentationA 71-year-old Swiss farmer with a history of recurring basal cell carcinoma and metastasized pancreatic neuroendocrine tumor presented with signs of sepsis after a three-day history of general weakness, malaise and fever. Clinical and echocardiographic findings, as well as persistent bacteremia were consistent with mitral valve endocarditis caused by T. pyogenes. The patient’s condition gradually improved under antibiotic treatment with piperacillin/tazobactam (empiric therapy of sepsis), and later penicillin G based on resistance testing. He was discharged after 13 days and continued outpatient antibiotic therapy with ceftriaxone, resulting in a total antibiotic treatment duration of six weeks. This is the first literature review of T. pyogenes endocarditis in humans. Among nine cases of T. pyogenes endocarditis, three patients had documented contact with farm animals and five had an underlying condition that compromised the immune system. While antibiotic resistance of T. pyogenes is an emerging concern, susceptibility to beta-lactam antibiotics seems to persist. The mortality of T. pyogenes endocarditis described in the literature was high, with 66% of patients not surviving the disease.ConclusionsT. pyogenes is a rare causative organism of infectious endocarditis in humans and descriptions are mainly restricted to case reports. In our review of the literature, we found that both an impaired immune system and contact with farm animals might be risk factors. Growth of T. pyogenes in blood cultures is unlikely to be missed during routine analysis, as it shows marked beta-hemolysis on blood agar culture plates, which generally leads to further characterization of the bacteria. Susceptibility to penicillin, ceftriaxone, and macrolides seems to be retained and the reported mortality in the few patients with T. pyogenes endocarditis is high.

Short course antibiotic treatment of Gram-negative bacteraemia (GNB5): a study protocol for a randomised controlled trial

IntroductionProlonged use of antibiotics is closely related to antibiotic-associated infections, antimicrobial resistance and adverse drug events. The optimal duration of antibiotic treatment for Gram-negative bacteremia (GNB) with a urinary tract...

Retrospective review of the epidemiology, microbiology, management and outcomes of intra-cranial abscesses at a neurosurgical tertiary referral centre, 2018–2020

BackgroundIntracranial abscesses are rare but serious, and are associated with significant morbidity and mortality. Due to both the rarity and severity of these infections, well-controlled trials have not been reported in the literature, and optimal management is a matter for expert opinion. Advances in surgical management have improved outcomes and increased rates of microbiological diagnosis. However, the approach to antimicrobial chemotherapy varies considerably, including the choice of antibiotic, the duration of treatment, and the timing of oral switch.MethodsWe conducted a retrospective review of 43 cases of intracranial abscesses from a large, tertiary neurosurgical centre in London, UK, between 2018 and 2020, including 29 primary intra-parenchymal abscesses, 11 subdural abscesses and 3 extradural abscesses.ResultsThe majority of cases had surgical intervention; 6/43 (14%) required repeat intervention (all intra-parenchymal abscesses). A microbiological diagnosis was made in 83% of cases. Intravenous antibiotics were given for a median of 33 days (IQR 23–44 days), with a variable duration of oral follow-on antibiotics. Total duration of antibiotic treatment ranged from 0 to 467 days. Only three patients from our cohort are known to have died.ConclusionShorter courses of intravenous antibiotics for brain abscesses were not associated with increased mortality. In the absence of well-controlled trials, a national registry of intracranial abscesses would provide invaluable data to inform optimal treatment.

Early Switch From Intravenous to Oral Antibiotics in Skin and Soft Tissue Infections: An Algorithm-Based Prospective Multicenter Pilot Trial.

BackgroundIn hospitalized patients with skin and soft tissue infections (SSTIs), intravenous (IV) empiric antibiotic treatment is initiated. The best time point for switching from IV to oral treatment is unknown. We used an algorithm-based decision tree for the switch from IV to oral antibiotics within 48 hours and aimed to investigate the treatment outcome of this concept.MethodsIn a nonrandomized trial, we prospectively enrolled 128 patients hospitalized with SSTI from July 2019 to May 2021 at 3 institutions. Clinical and biochemical response data during the first week and at follow-up after 30 days were analyzed. Patients fulfilling criteria for the switch from IV to oral antibiotics were assigned to the intervention group. The primary outcome was a composite definition consisting of the proportion of patients with clinical failure or death of any cause.ResultsNinety-seven (75.8%) patients were assigned to the intervention group. All of them showed signs of clinical improvement (ie, absence of fever or reduction of pain) within 48 hours of IV treatment, irrespective of erythema finding or biochemical response. The median total antibiotic treatment duration was 11 (interquartile range [IQR], 9–13) days in the invention group and 15 (IQR, 11–24) days in the nonintervention group (P < .001). The median duration of hospitalization was 5 (IQR, 4–6) days in the intervention group and 8 (IQR, 6–12) days in the nonintervention group (P < .001). There were 5 (5.2%) failures in the intervention group and 1 (3.2%) in the nonintervention group after a median follow-up of 37 days.ConclusionsIn this pilot trial, the proposed decision algorithm for early switch from IV to oral antibiotics for SSTI treatment was successful in 95% of cases. Clinical Trials Registration. ISRCTN15245496

No obesity paradox in patients with community-acquired pneumonia \u2013 secondary analysis of a randomized controlled trial

BackgroundObesity is associated with an increased risk for several chronic conditions and mortality. However, there are data in support of beneficial outcome in acute medical conditions such as community-acquired pneumonia (CAP), termed “obesity paradox”. The aim of this study was to test the association of BMI with clinical outcomes in a large randomized clinical trial of patients hospitalized with CAP.Design and MethodsIn total, 773 patients hospitalized with CAP were included in this study. Patients were stratified into four groups according to their baseline BMI (underweight <18.5, normal weight 18.5–25, overweight 25–30, and obese >30 kg/m2). The primary endpoint was time to clinical stability (TTCS). Secondary endpoints included 30-day mortality, ICU admission rate, CAP complications, and duration of antibiotic treatment.ResultsBMI and TTCS had a U-shaped association with shortest TTCS among patients at an overweight BMI of 28 kg/m2. In patients with obesity, there was a trend towards reduced hazards to reach clinical stability when compared to patients with normal weight (HR 0.82; 95%CI, 0.67–1.02; p = 0.07). In underweight BMI group TTCS was prolonged by 1 day (HR 0.63; 95%CI, 0.45–0.89; p = 0.008). There was no difference in mortality or ICU admission rates between BMI groups (p > 0.05). While in the underweight BMI group the total duration of antibiotic treatment was prolonged by 2.5 days (95%CI, 0.88–4.20, p = 0.003), there was no difference in patients with obesity.ConclusionsThe overweight BMI group had shortest time to clinical stability. While underweight patients face adverse clinical outcomes, there is neither beneficial, nor adverse outcome in patients with obesity hospitalized for CAP.ClinicalTrials.gov (registration no. NCT00973154).

Periprosthetic Infections of the Shoulder Joint: Characteristics and 5-Year Outcome of a Single-Center Series of 19 Cases.

Periprosthetic shoulder infection (PSI) remains a devastating complication after total shoulder arthroplasty (TSA). Furthermore, there is a paucity in the literature regarding its diagnostic and therapeutic management, especially the absence of therapy concepts devised exclusively for PSI. The aim of the presenting study is to examine the characteristics and outcome of patients with PSI who were treated according to well-established algorithms developed originally for periprosthetic joint infection (PJI) of the hip and knee and determine if these algorithms can be applied to PSI. This single-center case series included all patients with a PSI presenting between 2010 and 2020. Recorded parameters included age, sex, affected side, BMI, ASA score, Charlson comorbidity index, preoperative anticoagulation, indication for TSA (fracture, osteoarthritis or cuff-arthropathy), and type of infection (acute or chronic PSI). The outcome was divided into treatment failure or infect resolution. Staphylococcus epidermidis and aureus were the commonest infecting pathogens. Acute PSI was mainly treated with debridement, irrigation, and retention of the prosthesis (DAIR) and chronic cases with two/multiple-stage exchange. The treatment failure rate was 10.5%. C-reactive protein was preoperatively elevated in 68.4% of cases. The mean number of operative revisions was 3.6 ± 2.6, and the mean total duration of antibiotic treatment was 72.4 ± 41.4 days. The most administered antibiotic was a combination of clindamycin and fluoroquinolone. In summary, the data of the current study suggest that therapeutical algorithms and recommendations developed for the treatment of PJI of the hip and knee are also applicable to PSI.

Comparison of the clinical characteristics of community-acquired acute pyelonephritis between male and female patients

BackgroundCommunity-acquired acute pyelonephritis (CA-APN) is relatively rare in men. This study aimed to compare the clinical characteristics of CA-APN between male and female patients. MethodsWe prospectively collected the clinical and microbiological data of hospitalized CA-APN patients aged ≥19 years in South Korea from March 2010 to February 2011 in 11 hospitals and from September 2017 to August 2018 in 8 hospitals. Only the first episodes of APN of each patient during the study period were included. ResultsFrom 2010 to 2011, 573 patients from 11 hospitals were recruited, and from 2017 to 2018, 340 patients were recruited from 8 hospitals. Among them, 5.9% (54/913) were male. Male patients were older (66.0 ± 15.2 vs. 55.3 ± 19.0 years, P < 0.001), had a higher Charlson comorbidity index (1.3 ± 1.5 vs. 0.7 ± 1.2, P = 0.027), and had a higher proportion of structural problems in the urinary tract (40.7% vs. 6.1%, P < 0.001) than female patients. Moreover, the total duration of antibiotic treatment was longer (21.8 ± 17.8 d vs. 17.3 ± 9.4 d, P = 0.001) and the proportion of carbapenem usage was higher (24.1% vs. 9.5%, P = 0.001) in men than in women. Male patients were hospitalized for longer durations than female patients (median, 10 d vs. 7 d, P < 0.001). ConclusionsMale CA-APN patients were older and had more comorbidities than female CA-APN patients. In addition, male patients received antibiotic treatment for a longer duration than female patients.

A Comparison of the Epidemiology, Clinical Features, and Treatment of Acute Osteomyelitis in Hospitalized Children in Latvia and Norway.

Background and objectives: Paediatric acute osteomyelitis (AO) may result in major life-threatening and limb-threatening complications if not recognized and treated early. The management of AO may depend on local microbial prevalence and virulence factors. This study compares the approach to paediatric AO in hospitals in two countries—Latvia and Norway. Materials and Methods: The study includes patients with AO hospitalized in the paediatric department in the Norwegian hospital Sørlandet Sykehus Kristiansand (SSK), in the period between the 1st of January 2012 and the 31st of December 2019. The results from SSK are compared to the results of a published study of AO in patients hospitalized at the Children’s Clinical University Hospital (CCUH) in Riga, Latvia. Results: The most isolated pathogen from cultures in both hospitals was S. aureus (methicillin-sensitive). The lower extremity was the most affected body part (75% in CCUH, 95% in SSK), the main clinical symptom was pain (CCUH 92%, SSK 96.6%). Deep culture aspiration was most often taken intraoperatively in CCUH (76.6%) and percutaneously in SSK (44.8%). Oxacillin was the most applied antibiotic in CCUH (89.4%), and Cloxacillin in SSK (84.6%). Combined treatment with anti-Staphylococcal penicillins and Clindamycin was administered in 25.5% and 33.8% of CCUH and SSK patients, respectively. The median duration of the intravenous antibacterial treatment in CCUH and SSK was 15 and 10 days, respectively, and a switch to oral therapy was mainly made at discharge in both hospitals. The median total duration of antibiotic treatment was 25 days in CCUH and 35 days in SSK. 75% of CCUH and 10.3% of SSK patients were treated surgically. Complications were seen in 47% of patients in CCUH and in 38% in SSK. Conclusions: The transition to oral antibacterial treatment in both hospitals was delayed, which suggests a lack of criteria for discontinuation of intravenous therapy and could potentially contribute to longer hospitalization, higher cost of treatment and risk of complications. The use of more invasive techniques for deep culturing and significantly more common surgical interventions could possibly be linked to a higher complication rate in AO patients treated at the Latvian hospital.

Changes in Clinical Characteristics of Community-Acquired Acute Pyelonephritis and Antimicrobial Resistance of Uropathogenic Escherichia coli in South Korea in the Past Decade

This study examined changes in the clinical characteristics of community-acquired acute pyelonephritis (CA-APN) in South Korea between the period 2010–2011 and 2017–2018. We recruited all CA-APN patients aged ≥19 years who visited eight hospitals in South Korea from September 2017 to August 2018, prospectively. Data collected were compared with those from the previous study in 2010–2012, with the same design and participation from 11 hospitals. A total of 617 patients were enrolled and compared to 818 patients’ data collected in 2010–2011. Escherichia coli was the most common causative pathogen of CA-APN in both periods (87.3% vs. 86.5%, p = 0.680). E. coli isolates showed significantly higher antimicrobial resistance against fluoroquinolone (32.0% vs. 21.6%, p < 0.001), cefotaxime (33.6% vs. 8.3%, p < 0.001), and trimethoprim/sulfamethoxazole (37.5% vs. 29.2%, p = 0.013) in 2017–2018 than in 2010–2011. Total duration of antibiotic treatment increased from 16.55 ± 9.68 days in 2010–2011 to 19.12 ± 9.90 days in 2017–2018 (p < 0.001); the duration of carbapenem usage increased from 0.59 ± 2.87 days in 2010–2011 to 1.79 ± 4.89 days in 2010–2011 (p < 0.001). The median hospitalization was higher for patients in 2017–2018 than in 2010–2011 (9 vs. 7 days, p < 0.001). In conclusion, antimicrobial resistance of E. coli to almost all antibiotic classes, especially third generation cephalosporin, increased significantly in CA-APN in South Korea. Consequently, total duration of antibiotic treatment, including carbapenem usage, increased.

Acute suppurative thyroiditis with thyroid abscess in adults: clinical presentation, treatment and outcomes

BackgroundAbscess in the thyroid gland is a rare but severe infectious disease. The condition can have anatomic or iatrogenic underlying causes. If untreated it could be fatal. Pathogens vary considerably. Treatment is intravenous antibiotics, drainage, and sometimes surgery.MethodsThe electronic medical records of all adult patients with acute thyroiditis 2003–2017 treated at the Karolinska University Hospital (catchment area 2 million) in Sweden were systematically reviewed.ResultsFive patients were found in the catchment area. One patient from another region but known to us was also included. Thus, six patients (aged 28–73 years) were included in the study. Median length of hospital stay was 7.5 days (4–79 days). All were treated with antibiotics (intravenous n = 5, oral n = 1). Total antibiotic treatment duration was 13.5 days (10–41 days). Blood cultures were positive in three (streptococcus pneumonia, streptococci sanguineous, pepto streptococci), deep tissue culture in three (Escherichia coli, Candida, Hemophilic influenza) and no positive culture at all in two. Drainage was used in three patients. All patients recovered without recurrences. Surgery was performed twice in the acute phase in one. There was no recurrence during 7 years (3–12) of follow-up, but one patient died after three years (severe heart failure and pneumonia).ConclusionThyroid abscess in adults is extremely rare nowadays in the developed world. With prompt antibiotic therapy, drainage and in some cases thyroidectomy the prognosis seems favourable.

Effect of Candida albicans bronchial colonization on hospital-acquired bacterial pneumonia in patients with systemic lupus erythematosus.

To investigate the effect of Candida albicans airway colonization on hospital-acquired bacterial pneumonia (HABP) in patients with systemic lupus erythematosus (SLE). SLE patients with HAP were enrolled in this retrospective cohort study from January 2015 to December 2018. According to the culture results of respiratory tract secretions and antifungal treatment, patients were divided into non-C. albicans colonization group (NCG), C. albicans colonization with antifungal treatment group (CTG) and C. albicans colonization without antifungal treatment group (CNTG). Twenty-eight days of all-cause mortality after the onset of HABP of each group was assessed, total duration of antibiotic treatment, changes of inflammatory cytokines and markers of immune status were documented. A total of 269 SLE patients with HABP were finally included in the study. Among them, 69.1% (186/269) were found C. albicans airway colonization, and 36.1% (97/269) received antifungal treatment. No difference of 28 days of all-cause mortality after HABP onset was found among the three groups (10.8% vs. 13.4% vs. 15.7%, P>0.05). Duration of antibiotic treatment of HABP due to Acinetobacter baumannii was shorter in CTG (11.21±2.45 days) than that in CNTG (12.89±3.87 days) as well as HABP due to Pseudomonas aeruginosa (10.57±2.66 vs. 12.56±3.04 days) (P<0.05, respectively). Antifungal treatment could decrease the level of interleukin-1β, interleukin-6, tumor necrosis factor-α and interferon-γ in CTG than in CNTG (P<0.05, respectively). In addition, it could regulate immune function by decrease the concentration of interleukin-17 and elevate the counts of CD4+Th lymphocyte as well (P<0.05, respectively). C. albicans airway colonization was not associated with HABP mortality in SLE patients. Antifungal therapy in these patients might shorten the duration of antibiotics in treating HABP due to A. baumannii and P. aeruginosa.

1451. Change in Clinical Characteristics of Community-Acquired Acute Pyelonephritis in South Korea: Comparison Between 2010–2011 and 2017–2018

BackgroundThe aim of this study was to examine the change in clinical characteristics of community-acquired acute pyelonephritis (CA-APN) in South Korea between 2010–2011 and 2017–2018.MethodsWe recruited all CA-APN patients with age ≥19 years who visited 4 hospitals in South Korea from September 2017 to August 2018, prospectively. The inclusion criteria were: (i) presence of fever (body temperature ≥37.8°C), (ii) pyuria [≥5–9 white blood cells per high power field (WBC/HPF)], and (iii) clinical symptoms or signs relevant to APN. Patients diagnosed with APN more than 48 hours after admission, those transferred from other hospitals during treatment of APN, those with other reasons for fever and pyuria, and those with insufficient data were excluded. Each patient was included for the first episode during the study period. The collected data were compared with those from the previous study with the same design in 2010–2012, in which the same hospitals were participated.ResultsA total of 349 and 472 patients were recruited during 2017–2018 and 2010–2011, respectively. E. coli was the most common causative pathogen for CA-APN in both periods (87.5% vs. 86.6%, P = 0.727). Significantly higher antimicrobial resistance against fluoroquinolone (33.5% vs. 21.0%, P = 0.001), cefotaxime (34.8% vs. 7.6%, P P = 0.040) were observed for E. coli isolates in 2017–2018 compared with those in 2010–2011. The patients in 2017–2018 were older (60.71±17.29 vs. 55.77±18.60, P <0.001) and had higher Charlson’s comorbidity index (1.04±1.39 vs. 0.68±1.17, P<0.001) than those in 2010–2011. Total duration of antibiotic treatment increased from 15.40 ± 6.35 days in 2010–2011 to 21.74 ± 11.72 days in 2017–2018, P <0.001); the proportion of patients using carbapenem increased from 6.1% in 2010–2011 to 26.6% in 2010–2011 (P < 0.001). The median days of admission was higher for patients in 2017–2018 than those in 2010–2011 (10 vs. 8, P < 0.001).ConclusionPatients with CA-APN in South Korea were aging. Antimicrobial resistance of E. coli to almost all antibiotic classes, especially third-generation cephalosporin, increased significantly and total duration of antibiotic treatment and proportion of carbapenem usage increased, consequently. Disclosures All authors: No reported disclosures.

165. Comparative Effectiveness of Oral Fluoroquinolones vs. β-Lactams for the Treatment of Patients with Enterobacteriaceae Bloodstream Infections

BackgroundFluoroquinolones (FQ) are associated with unacceptable rates of adverse drug events (ADE) and drug resistance. Safe and effective alternative oral agents are needed for definitive treatment of Enterobacteriaceae bloodstream infections (BSI). This study aims to determine whether treatment failure rates were similar in patients who received FQ or β-lactams (BL) for stepdown treatment of Enterobacteriaceae BSI.MethodsWe conducted a retrospective cohort study comparing oral BL vs. FQ as definitive therapy for patients with BSI due to Escherichia coli, Klebsiella spp., or Proteus spp. Eligible patients were ≥18 years old with a monomicrobial BSI treated with a single definitive oral antibiotic. Patients with a total antibiotic treatment duration of <6 or >21 days were excluded. Groups were matched based on age and gender. The primary outcome was treatment failure defined as recurrence or all-cause mortality within 90 days with a 10% non-inferiority margin. Secondary outcomes were death or recurrence within 30 and 90 days, symptomatic urinary tract infection (UTI) or BSI within 30 days, and the safety outcome of antibiotic-related ADE.ResultsThe average age was 68 years, with 94% males. In the BL group, 80% had a urinary source of infection vs. 69% of the FQ group. The majority of patients had source control (88% of BL group vs. 83% of FQ group). The most common pathogens were E. coli (66%) and K. pneumoniae (24%). Cefpodoxime (71%) and ciprofloxacin (85%) were the most commonly used oral antibiotics. The average duration of oral therapy was 9.2 vs. 9.6 days and total duration was 14.4 vs. 13.9 days in the BL vs. FQ group, respectively. The primary outcome occurred in 15.4% of the BL group vs. 12.3% of the FQ group (P = 0.8002, RR = 0.80, 95% CI = 0.33–1.90). No deaths were directly attributed to infection. Symptomatic UTI or BSI within 30 days occurred in 20% of BL patients vs. 21.5% of FQ patients (P = 1.0000, RR = 1.07, 95% CI = 0.55–2.11). Mortality or recurrence at 30 days were similar between groups (4.6% of BL group vs. 9.2% of FQ group, P = 0.4920, RR = 2.00, 95% CI = 0.52–7.66). One FQ patient experienced an antibiotic-related ADE (C. difficile infection).ConclusionBL are non-inferior to FQ and appear to be as effective for oral step-down treatment of Enterobacteriaceae BSI without the associated risks.Disclosures All authors: No reported disclosures.

Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study.

Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration. To examine predictors and outcomes associated with excess duration of antibiotic treatment. Retrospective cohort study. 43 hospitals in the Michigan Hospital Medicine Safety Consortium. 6481 general care medical patients with pneumonia. The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment. Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Retrospective design; not all patients could be contacted to report 30-day outcomes. Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes. Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.

Periprosthetic joint infection: current concepts and outlook.

Periprosthetic joint infection (PJI) is a serious complication occurring in 1% to 2% of primary arthroplasties, which is associated with high morbidity and need for complex interdisciplinary treatment strategies.The challenge in the management of PJI is the persistence of micro-organisms on the implant surface in the form of biofilm. Understanding this ability, the phases of biofilm formation, antimicrobial susceptibility and the limitations of host local immune response allows an individual choice of the most suitable treatment.By using diagnostic methods for biofilm detection such as sonication, the sensitivity for diagnosing PJI is increasing, especially in chronic infections caused by low-virulence pathogens.The use of biofilm-active antibiotics enables eradication of micro-organisms in the presence of a foreign body. The total duration of antibiotic treatment following revision surgery should not exceed 12 weeks.Cite this article: EFORT Open Rev 2019;4:482-494. DOI: 10.1302/2058-5241.4.180092

Paediatric focal intracranial suppurative infection: a UK single-centre retrospective cohort study

BackgroundPaediatric focal intracranial suppurative infections are uncommon but cause significant mortality and morbidity. There are no uniform guidelines regarding antibiotic treatment. This study reviewed management in a tertiary healthcare centre in the United Kingdom and considers suggestions for empirical treatment.MethodsA retrospective, single-centre cohort review of 95 children (< 18 years of age) with focal intracranial suppurative infection admitted between January 2001 and June 2016 in Newcastle upon Tyne, United Kingdom. Microbiological profiles and empirical antibiotic regimens were analysed for coverage, administration and duration of use. Mortality and neurological morbidity were reviewed. Data was analysed using t-tests, Mann-Whitney U tests, independent-samples median tests, and χ2-tests where appropriate. P-values < 0.05 were considered statistically significant.ResultsEstimated annual incidence was 8.79 per million. Age was bimodally distributed. Predisposing factors were identified in 90.5%, most commonly sinusitis (42.1%) and meningitis (23.2%). Sinusitis was associated with older children (p < 0.001) and meningitis with younger children (p < 0.001). The classic triad was present in 14.0%.43.8% of 114 isolates were Streptococcus spp., most commonly Streptococcus milleri group organisms. Twelve patients cultured anaerobes.Thirty one empirical antibiotic regimens were used, most often a third-generation cephalosporin plus metronidazole and amoxicillin (32.2%). 90.5% would have sufficient cover with a third generation cephalosporin plus metronidazole. 66.3% converted to oral antibiotics. Median total antibiotic treatment duration was 90 days (interquartile range, 60–115.50 days).Mortality was 3.2, 38.5% had short-term and 24.2% long-term neurological sequelae.ConclusionsPaediatric focal intracranial suppurative infection has a higher regional incidence than predicted from national estimates and still causes significant mortality and morbidity. We recommend a third-generation cephalosporin plus metronidazole as first-choice empirical treatment. In infants with negative anaerobic cultures metronidazole may be discontinued.

Factors associated with sequelae after treatment of hematogenous pyogenic vertebral osteomyelitis

ObjectivesFunctional disability may persist after completing treatment for hematogenous pyogenic vertebral osteomyelitis (HPVO). The objective of this study was to identify factors associated with residual sequelae after treatment of HPVO. MethodsWe conducted a retrospective study of patients diagnosed with HPVO at 5 tertiary-care hospitals between January 2005 and December 2012. Sequelae were defined as an inability to walk without assistance, bladder/bowel incontinence, and/or unresolved pain that required analgesic therapy at 12 months after completing the HPVO treatment. ResultsOf the 279 patients with microbiologically proven HPVO, 79 (28.3%) had sequelae at 12 months posttherapy. Independent risk factors for sequelae were neurologic deficit (adjusted odds ratio [aOR], 3.38), recurrence within 12 months (aOR, 2.45), age ≥ 65 years (aOR, 2.05), C-reactive protein level ≥ 10 mg/dL (aOR, 2.01), and epidural/paravertebral abscess (aOR, 2.00). Among 58 patients with neurologic deficit, sequelae rates differed according to the surgical strategy, as follows: 28.6% (early surgery [<48 h]), 55.0% (delayed surgery [≥48 h]), and 66.7% (no surgery) (P = 0.03). Among the 170 patients with abscess, early drainage (<72 h) was an independent protective factor for sequelae (aOR, 0.35). The 12-month recurrence rates differed according to the total duration of antibiotic treatment, as follows: 20.5% (4–6 weeks), 18.4% (6–8 weeks), and 5.2% (≥8 weeks) (P < 0.001). ConclusionsA substantial proportion of patients with HPVO experienced sequelae after completing treatment. Early surgery for neurologic deficit, early drainage of abscess, and antibiotic therapy of appropriate duration to reduce recurrence may prevent development of sequelae in patients with HPVO.

International survey of paediatric infectious diseases consultants on the management of community-acquired pneumonia complicated by pleural empyema.

Community-acquired pneumonia (CAP) complicated by pleural empyema is an important paediatric problem. Antibiotic management decisions are made on the basis of little available data and without strong specific recommendations in guidelines. This was an online survey of paediatric infectious diseases (PID) physicians disseminated by major international professional organisations, examining empiric and targeted antibiotic choice, switch to oral antibiotics and duration of treatment for two hypothetical cases of contrasting severity. This study included 183 responses, mostly from North America, Western Europe and Australia/New Zealand. Increased disease severity was significantly associated with broader-spectrum and combination empiric and targeted antibiotic treatment, empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage and both longer intravenous (IV) and total duration of antibiotic treatment. Empirical MRSA coverage was also associated with local prevalence. Clinical progress was most important for determining the timing of the switch from IV to oral antibiotics. Few respondents chose antibiotics with activity against organisms associated with atypical pneumonia (e.g. Mycoplasma, Chlamydia), and most did not choose agents that inhibit protein synthesis (e.g. clindamycin), even in the case of a severe invasive group A streptococcal infection. Some variation in targeted treatment choices reflected areas of uncertainty, such as Streptococcus pneumoniae susceptibility breakpoints, comparative effectiveness of anti-staphylococcal penicillins and first-generation cephalosporins for serious S. aureus infections and linezolid and vancomycin for MRSA pneumonia. This international survey of PID physicians highlights the priority targets for clinical research to improve antibiotic treatment of CAP complicated by empyema. Interventions that might be studied include empirical antibiotic guidelines stratified by case severity, adjunctive empirical use of agents that inhibit protein synthesis (e.g. clindamycin) and approaches to encourage rapid IV-to-oral switch and shorter total antibiotic treatment.

Decompression alone versus fusion for pyogenic spondylodiscitis

Background ContextA spinal infection is a serious problem for a spine surgeon, and there is currently much debate regarding how best to treat pyogenic spondylodiscitis using antibiotics and the instrumentations that have been developed to date. PurposeThe purpose of this study was to determine which method is better for treating pyogenic spondylodiscitis. Study DesignA retrospective chart review was performed. Patient SampleThirty-one patients with pyogenic spondylodiscitis underwent surgical treatment between 2000 and 2016 at the authors' institution. Outcome MeasuresClinical outcomes were assessed using a visual analog scale (VAS). We measured translation and rotation on flexion and extension X-rays to identify instability. MethodsPatients were divided into two groups: Group I, decompression group; Group II, decompression plus fusion group. Group I exhibited no instability according to a preoperative radiographic study, whereas Group II exhibited instability. Both groups were compared with respect to demographics and laboratory findings, including tests to determine C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR), organisms, and the total duration of antibiotic treatment after the operation. We compared the results of the preoperative, postoperative, and last follow-up radiographic examinations of the sagittal alignment of the infected segment. This study was supported by a clinical research fund (4,500 dollars) from the National Health Insurance Service, Ilsan Hospital. ResultsA total of 31 patients were included; 22 (71%) were in Group I and 9 (29%) were in Group II. On radiological examination, the mean preoperative translation and rotation values in Group I were 2.45±1.22 mm and 5.64±1.98°, and in Group II were 5.35±1.65 mm and 12.01±4.22°. At the last follow-up, the mean translation and rotation values in Group I were 1.95±1.75 mm and 2.69±1.61°, and in Group II were 1.77±1.02 mm and 3.44±2.07°. Both Groups I and II exhibited stability after the operation. No differences were detected in preoperative ESR and CRP levels between the two groups. Group I, compared with Group II, experienced a shorter duration of treatment with antibiotics and normalization of ESR and CRP levels after the operation and a shorter hospitalization period. ConclusionsIf the appropriate antibiotics are administered quickly when there is no instability, decompression alone is effective; however, if instability is detected, decompression plus fusion can be used to achieve stability.